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Reviews of Educational Material  |   July 2016
A Case Approach to Perioperative Drug-Drug Interactions.
Author Notes
  • University of Utah, Salt Lake City, Utah. ken.b.johnson@hsc.utah.edu
  • (Accepted for publication April 12, 2016.)
    (Accepted for publication April 12, 2016.)×
Article Information
Reviews of Educational Material / Pharmacology
Reviews of Educational Material   |   July 2016
A Case Approach to Perioperative Drug-Drug Interactions.
Anesthesiology 7 2016, Vol.125, 258-259. doi:10.1097/ALN.0000000000001146
Anesthesiology 7 2016, Vol.125, 258-259. doi:10.1097/ALN.0000000000001146
In A Case Approach to Perioperative Drug-Drug Interactions, Drs. Marcucci and Hutchens assembled a team of 13 editors with expertise in anesthetic pharmacology and perioperative medicine to prepare an easy-to-read yet comprehensive treatise of drug–drug interactions (DDIs). With nearly 200 contributing authors and 220 chapters, the book provides a first of its kind in-depth look at DDIs that perioperative clinicians will find useful in anesthesia patient care.
The editors quickly established the rationale for the book. They point out that the U.S. Food and Drug Administration has approved more than 10,000 prescription medications; these medications often contain more than 1 active ingredient. Exploring possible interactions between approved drugs, along with supplements and foods known to influence drug metabolism, makes for millions of potential DDIs. It is impossible for a clinician to stay up-to-date on existing and new DDIs. This book represents a comprehensive solution to that dilemma of clinicians.
A glance through the table of contents quickly suggests to the reader that this will be an entertaining read. The book consists of catchy chapter titles, such as “Naturally Occurring and Nasty,” “Royal Flush,” and “Keep an ‘Ion’ the Twitches,” to engage readers as authors present complex concepts in concise brief chapters. The intent is to break up a large and overwhelming topic into smaller consumable segments and present them in a memorable and easily understood form that has clinical utility at the bedside.
The book is organized into two major sections: didactics and case vignettes. The didactic section orients readers to essential concepts regarding mechanisms of interactions and their associated clinical implications. Core concepts include pharmacokinetic and pharmacodynamic interactions, an orientation to oxidative and conjugative metabolism, and transporters involved in drug absorption. The chapters describing cytochrome P450 enzymes (CYP450) and 5-diphospho-glucuronosyl transferase enzymes are particularly interesting, as this topic will likely become more of a focus in personalized medicine in anesthesia.
Where available, authors present information describing the pharmacogenomics that play a role in drug behavior and/or in DDIs by describing drug–gene interactions. This rapidly emerging field of discovery is of particular interest to clinical anesthesiologists. Anesthesia care providers spend their day administering potentially dangerous drugs to patients. Patients may exhibit a wide range of unanticipated responses, some of which are harmful. Work characterizing polymorphisms of selected CYP isoenzymes has already shed light on interpatient variability. The authors of the chapter on pharmacogenomics point out that as research in this domain advances, it is reasonable to expect that genetic mapping will unveil even more polymorphisms that influence drug receptors, transport, and metabolism. As genotyping becomes more accessible, there may come a time when pharmacogenomics becomes germane in personalized medicine, especially in the field of anesthesiology.
The book introduces the “Fatal Forty,” a list of what the authors deem the most important DDIs a perioperative physician “must know.” This list emphasizes commonly prescribed drugs with a low therapeutic index, drugs that either inhibit or induce metabolic enzymes, prodrugs, and drugs that are sensitive to changes in enzyme activity. The authors acknowledge that “Fatal” is perhaps a misnomer, as drugs on this list, if properly dosed, are not fatal.
The second major section of the book, the case vignettes, makes up the bulk of the text. Each case vignette is presented as a case report. Chapters begin with an abstract followed by details of a patient’s course experiencing a DDI. This is followed by a discussion, “Take-Home Points,” and summary. Case vignettes are grouped by drug classifications. Each drug class is introduced by a brief chapter by one of the editors, emphasizing key points to be raised in the category of case vignettes that follow. Classifications include inhalation agents, intravenous anesthetics, local anesthetics, opioids, nonopioids, benzodiazepines and other sedatives, neuromuscular blocking agents, antibiotics and antifungals, cardiovascular medications, coagulation modifiers, immunosuppressants, antiemetics, chemotherapeutic drugs, neuropsychiatric drugs, drugs that prolong QT intervals, and food and nutrition. Where appropriate, case vignette subtitles emphasize drugs from the Fatal Forty list and the CYP enzymes at play in the DDI of interest.
The editors recognize that the overall text is somewhat daunting to read. To ease readers into their text, they suggest that if 40 is too many, interested clinicians should develop their own top 10 list of DDIs relevant to their practice. For the trainee, editors suggest a selected reading list of core chapters by the level of residency training. The authors have prepared each case vignette as a stand-alone chapter that can be read in no particular order. Each subsection addressing a particular drug classification is organized such that the most common or well-described DDIs are presented first, followed by those that are less common or poorly understood.
Clinicians will likely want to access this book’s content in the perioperative arena. Using the e-book version, clinicians will be able to access the content of this excellent and innovative textbook on any reading device.
In the realm of perioperative clinical pharmacology textbooks, A Case Approach to Perioperative Drug-Drug Interactions stands alone as a comprehensive compilation of hundreds of clinically relevant DDIs presented in an organized and easily accessible format. It is a timely piece that integrates the basic science behind DDIs with case reports describing the clinical presentation of DDIs. It introduces clinicians to important concepts in pharmacogenomics, an advance in personalized medicine that will likely have a significant impact in perioperative care. This book embodies the future of what should be expected of perioperative clinicians with regard to their awareness and understanding of DDIs.
Ken B. Johnson, M.D., University of Utah, Salt Lake City, Utah. ken.b.johnson@hsc.utah.edu